Management of a Child with Measles
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Management of a Child with Measles
Dr. Anil Mokashi. MD., DCH., FIAP, PhD.
Measles is a disease associated with varied local customs and beliefs, which
have a major influence on the management. Management of the CUSTOMS AND
BELIEFS is at times more important than the drugs in measles. Harmless
practices like a black thread around neck or a visit to temple can be
allowed. We should discourage harmful practices like “fomenting with hot
bricks, instilling cow’s milk drops in nostrils and eyes, giving him a purge;
all in an attempt to bring out the rash completely.” Few customs could be
encouraged for the benefit of the child e.g. applying oil all over the body
or feeding rose jam, groundnuts, curds, black dried grapes. Every mother and
grand mother will have different sets of beliefs. A doctor must know local
customs and beliefs in that area for successful management of a child with
We will discuss the management under 4 headings
Management in OPD
Indications for hospitalization
Management in hospital
Follow up examination after measles
A. Management in OPD:
There is no drug available that can act on the measles viruses. Outcome of
the disease depends largely on adequate nutrition, fluid intake, symptomatic
therapy, early diagnosis and treatment of complications.
Fluid Intake: In a sick child fluid intake may be low. There is more
evaporative loss due to fever and rapid respiratory rate. Fluid may be lost
due to diarrhoea. All these factors in a child, who has only a loti-full of
water in his body, make him prone for dehydration. Ensuring adequate fluid
intake may be lifesaving.
Nutrition: Measles is severe in malnourished children. It is one of
the most common infectious diseases precipitating malnutrition. Malnutrition
is an important cause of death in measles. Nearly every child, who had
measles, loses weight. Appetite is lost during any febrile illness. On the
other hand more calories are needed. There is a tendency amongst families to
restrict diet during measles. Breast milk is incorrectly stopped during
diarrhoea after measles. Unless there is profuse diarrhoea; milk and routine
diet is advocated. Adequate nutrition ensures smooth sailing.
Diarrhoea: As diarrhoea in measles is directly due to viral infection
of the G.I. tract, antibiotics are not going to be useful. Oral rehydration
is the mainstay of treatment. Diarrhoea for more than 15 days may be due to
lactose intolerance, where withdrawl of milk is necessary or due to
secondary bacterial infection, when antibiotics will be curative. Continuing
rice-dal-vegetable kanji and breast milk in any diarrhoea is an essential
part of treatment.
Antibiotics: In disease as severe as measles, it is difficult not to
give antibiotics for a sick looking child. It is proved beyond doubts that
antibiotics do not prevent bacterial infection. Still everybody of us is
always tempted to give an antibiotic.
Symptomatic Therapy: Paracetamol for fever, chloral hydrate for
sedation, cough suppressive, skin lotion like caladryl to reduce itching,
steam inhalation to soothen respiratory mucosa and prevention of exposure to
bright light if child has photophobia are the symptomatic measures to be
taken routinely. Some children develop constipation which may need a soap
stick or liquid paraffin. Vitamin C may be given as it is supposed to prevent
corneal complications. All children with measles have low vitamin A levels
and one oral vitamin A dose ( Govt / inj aquasol given oraly) should be
B. Indications for hospitalization:
The most difficult and vital decision in management of measles is “which
child needs hospitalization.” The guideline given is useful to select “ at
risk children.” Optimum care is needed to save these lives.
Rash : if there is darkening, desquammation in large plaques or haemorrhages
in the rash.
Hoarseness of voice particularly if laryngeal obstruction is suspected.
Dehydration grade II or more
Blood and mucus in stools.
More than 10 stools in a day.
Convulsion or altered consciousness.
Respiratory distress with flaring of alae nasi.
Malnourished, underweight children.
Infant unable to suck due to soreness of mouth and tongue.
C. Management in hospital:
Laboratory and radiology can help the better Management. Investigations
should be done for a specific purpose. A “ routine list of investigations”.
For every child with measles is unnecessary. Following are the indications
and significance of each Diagnostic tool in management of measles.
Haemoglobin is done for (a) Pre-existing anemia (b) anemia during
measles (bone marrow suppression) (c) anemia after measles (iron and vitamin
Total and differential W.B.C. counts to suspect and diagnose the cause
of complications as bacterial. Increased total count with neutrophils
suggests bacterial complications.
ESR if done 1 month after measles can suggest the possibility of flare
up of tuberculosis. A westergren reading of more than 50mm at the end of 1st
hour should alert the doctor to search for further evidence of tuberculosis.
Tuberculin test is often negative during and for 6 weeks after
measles. A routine T.T. is done 6 weeks after in every case of measles at
some centers. We should do T.T. if child has fever for more than 15 days
duration after measles.
C.S.F. examination is indicated if child has altered consciousness or
X-Ray chest during the attack of measles, X-Ray chest can show (a)
bronchopnemonia or pneumonia following secondary bacterial infection. (b)
Bronchilolitis diagnosed by the findings of emphysema, rhonchii and
breathlessness. (c) Pre-existing tuberculosis, X-Ray chest 1 month after
measles can suggest the flare up of tuberculosis.
As described above SYMPTOMATIC CARE is essential. In a child with respiratory
distress, OXYGEN and suction of the oropharynx is the first step in bringing
the disturbed physiology to normalcy. GENTION VIOLET application for soreness
of mouth and tongue prevents fungal overgrowth. Codein is given to suppress
the distressing hacking cough.
INTRAVENOUS FLUIDS are required for correction of dehydration and for
maintenance. Electrolyte imbalance can complicate the picture. Generally a
second drip of polyelectrolyte solution like Isolyte or DLR-P serves the
purpose. Sodium bicarbonate is diluted and pushed I.V. if signs of acidosis
like deep rapid respiration are noted.
ANTIBIOTICS are given if child has bronchopneumonia, otitis media,
pyoderma or diarrhoea after subsidance of the rash. Antibiotic therapy is
tailored to suit the economic status of the parents. Omnatax, mikacin are
good in hospitalised children. In poor patients “ penicillin injection or
septran “ is the cheapest and best treatment.
STEROIDS Is a double edged weapon in the management of measles. In an
uncomplicated disease in initial stages steroids are harmful while in some
complications they are life saving. In active phase of viremia steroids will
suppress the immunological responses and the disease will be more severe. So
steroids are contraindicated when rash is in active phase. If a child with
measles has tuberculosis already, and is not on antitubercular drugs,
steroids will surely flare up the tuberculosis.
Steroids are indicated in encephalitis and toxemia with bronchopneumonia.
Dexamethasone is preferred over other steroids. So steroids should be used
more as “a life saving measure” than a routine measure in the management of
GAMMAGLOBULINS attenuate the severity of measles and are supposed to
prevent complication. In a serious child it should be given. Even though the
efficacy is not proved, it surely will not harm. Dose is 0.2 to 0.3 ml 10%
gammaglobulin subcutaneous or IM injection. The maximum efficacy is observed
if given within 5 days of exposure to measles.
If the child has (1) anemia with HB less than 5 gm% (2) toxemia or septicemia
(3) haemorrhagic complications, BLOOD TRANSFUSION many be needed. The dose is
20 ml/kg/day. Many times in seriously ill children, blood transfusion alters
In case of respiratory distress with predominant rhonchiri, BRONCHODILATORS
nebuliser, aminophylline 4 mg./kg/dose every 6-8 hourly helps in clearing the
respiratory passage. LANOXIN is indicated in C.C.F. diagnosed by anxiety,
heart rate above 200/minute, liver and spleeen palpable and mottled skin
VITAMINS AND MINERALS are given if there is pre-existing deficiency
and to meet the increased demands during illness. Vitamin C is supposed to be
useful in corneal lesions. Vitamin A is given if skin complications arise. B
Vitamins are given to ensure adequate marrow function which is suppressed by
measles. Vitamins can be given in injectable form during hospital stay, or
orally in the form of multivitamin C or AD drops.
Adequate nutrition must be established. Concentrated glucose given I.V. does
not supply adequate calories. 10 ml of 50% glucose will give hardly 20
calories. We have to give calories in thousands (1200 to 1500). If required
ryles tube feeding is given for first 2-3 days. A doctor should not be much
worried about child's digestive power. Cereals + pulses +fats + milk as
semisolid paste (not liquid) is the most suitable food. This type of kanji
meets the social, cultural, economic, nutritional requirements.
A proper RECORD OF PROGRESS is valuable in evaluating therapy. As
temperature, respiratory rate, number of stools settle down, it surely gives
an indications to a successful outcome. If weight is recorded at admission
and 15 days later, we can easily diagnose malnutrition at an earlier stage.
D. Follow up Examination at 1 month
After 1 month of illness child should be re-examined for 1) otitis media
2) chronic diarrhoea 3) weight loss or inadequate gain 4) flare up of
tuberculosis 5) neurological signs & symptoms 6) pyoderma 7) residual
respiratory complications 8) nutritional anemias.